Update on Transgender Families

In 2015, we did an updated edition of Pregnancy, Childbirth, and the Newborn: The Complete Guide. We added a few paragraphs on transgender people who identify as men and are pregnant, and other expectant families who are genderqueer, gender non-binary, and so on. We switched most of the language in the book to be gender neutral, but it is not perfectly so. In the process of making those changes and many other things I have learned since then, I’ve found several resources that are helpful for birth educators and doulas.

To any transgender or genderqueer folks who read this… I am still learning. If I mis-state anything here, feel free to comment on how I could do better.

Understanding Gender Identity

First, if you know your knowledge of transgender issues is limited, a great place to begin is “Guide to Being a Trans Ally“. It’s long, but well worth the read. (Many people also find the Genderbread Person to be a helpful tool for understanding these ideas.) For example, it defines sex, sexual orientation, gender, gender identity and gender expression, and all the ways terms are used. It also talks about how all these things can be a spectrum. (A side note: If you think biological sex is totally binary, not a spectrum, you’ll find this a fascinating post about in-utero development of sexual characteristics.)

For example, I am a cisgender woman, because I was assigned female at birth, and I identify as female, and my gender expression is female though not exactly “extremely feminine” (you’ll never see me in high heels or makeup!) And I am heterosexual.

A transgender man is someone who was assigned female at birth because of their biological sex characteristics, but internally identifies as male. Some transgender men are not “out of the closet” and don’t disclose their transgender status in their public life – they think of themselves as male and may ask those close to them to refer to them as male, but their gender expression in public is female or sometimes androgynous. Some transgender men express themselves as male – they dress in “male” clothing, may use mannerisms and speech patterns associated with men, and may have a male name but will openly define themselves as trans-male. Some express themselves as completely male and will never disclose any other identity – as the Guide says, they “just want to be seen as their gender-affirmed selves.” In your practice, although you wouldn’t have known it, you may have encountered these men as partners to a female-identified expectant mother.

Estimates on what percentage of the popular is gender variant range widely. The Williams Institute says 0.6% of Americans are transgender. The Transgender Law and Policy Institute says 2 – 5% of the population experience some gender dysphoria (an emotional / mental health condition that arises when someone’s gender expression and how other people refer to them and react to them does not align with their internal sense of who they are.)

It is very likely that younger people are more likely to identify as transgender than older people. When asked whether they identify as lesbian, gay, bi or transgender, 1.4% of those over 75 say yes, but 8.2% of those 20 – 39 do. (Source) This is likely not due to a change in actual incidence of homosexual orientation or transgender identity but more on social attitudes that make it more acceptable to acknowledge those feelings. This will mean that in the future, you will be more likely to knowingly encounter gender variant families than you were in the past.

Transgender Men and Pregnancy

A pregnant father would be someone who was assigned female at birth (and has a uterus, ovaries, and so on) but his internal sense of gender identity is male. There are also non-binary people and other people across the gender spectrum who carry and birth babies.

Some of those expectant parents will have an outward gender expression that is obvious to birth professionals, and they may also have a conversation with the professional about their gender identity, pronouns, and preferred terms (e.g. “I am the baby’s father, and you should refer to me as he / him”). Other transgender people may be more hesitant to reveal their gender identity to their caregivers, and may be cautious in how they dress and present themselves when coming for appointments – such as presenting more feminine than they otherwise might and not correcting the caregiver if they use female pronouns. However, this may increase their gender dysphoria. Dysphoria is often intense during pregnancy, and having your caregiver use ‘she’, ‘her’, ‘mother’ and other gendered terms frequently can increase that.

When birth professionals encounter clients who express themselves as gender variant, we need to know how to treat them with respect and honor their identity. And, because we will also quite possibly encounter other gender non-conforming people without knowing it, we should work on adapting our language at all times to welcome them in. And even if everyone in the room is cisgender, using gender-inclusive language helps to increase the visibility of transgender people and their rights for respectful language. And that includes language on websites and advertising where potential clients may look before coming in to determine whether they would be welcomed by your practice.

Health Care Experiences of Transgender People

Many transgender people have a history of bad encounters with health care providers: As many as one-fourth of gender variant people avoid health care services due to concerns about discrimination and harassment. (Source) “FTM youth said they frequently encountered verbal abuse and condescension from frontline health care staff such as receptionists: ‘I can’t even make it through the front door without staff staring at me, laughing at me, or whispering about my gender presentation.’ In the FTM youth group, all participants agreed that they did not feel safe receiving health care.” (Source) “One FTM youth found experiences with gynecological care especially upsetting:’There is a lack of sensitivity… The doctor was not sensitive to the fact that I experience myself as male and that this experience was overwhelming for me.’ Said one FTM adult,“I think for me it is respect and a willingness to respect your pronoun. I found that to be a huge problem. As somebody that hasn’t done any body alterations,it’s hard for people to switch pronouns and accept the pronoun [that I prefer].” (Source)

This page http://transequality.org/Issues/health.html offers brief, but helpful, recommendations for trans* people about accessing effective health care in general, and things they should consider, and talk to a supportive caregiver about.

Health Professionals Advancing LGBT Equality (previously known as the Gay & Lesbian Medical Association) has an excellent resource for health care providers on Guidelines for Care of LGBT Patients. It talks about how LGBT clients might “scan” a practice to see how friendly it is: they might look for gender-neutral language (pregnant parent, partner, and so on – not mother and father), non-discrimination statements, gender-neutral restroom signs, pride flags, intake forms that ask for relationship status not marital status, offer a check box for transgender, a line for preferred pronoun, and so on. Check it out for ideas that might apply to your practice.

Birth Professionals and Gender Variant Families

The Science and Sensibility blog hosted a post by Simon Adriane Ellis on Working with Gender Variant (Transgendered) Families which is an excellent summary for birth professionals (OB’s, midwives, doulas, childbirth educators, and so on) about how to work with gender variant people successfully. Some tips are:

Offer accommodations such as one-on-one classes, appointments at the beginning or end of the day, if you need to refer to another provider, you call ahead to provide the patient’s background.

Plan to offer additional emotional support – they may feel very isolated and may be struggling with gender dysphoria. [Note: Ellis also co-authored a journal article titled “Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family” which explores this parenting experience and says the over-arching theme was loneliness.]

Use sensitive language. It’s important to ask them what name, pronoun, and parenting term they would like to be addressed by.

“Don’t let your curiosity get the best of you” – it may be tempting to ask the whole history of their gender identity… only ask what you need to know to care for them

I think a really important sentence from the article is “The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s well-being. But the truth is: with very few exceptions, there is no one with more experience.”

ACNM has a position statement on Transgender/Transsexual/Gender Variant Health Care which includes some pointers to additional research.

Inclusive Language in Childbirth Classes

I attended an in-service by Kristin Kali, from Maia Midwifery on how language matters for LGBT students in childbirth classes. Here are some of my takeaway notes from that:

Using very gendered language like “mom” and “dad” can be very alienating for many families: single parents, gay or lesbian couples, surrogates, donor fathers, polyamorous families where there will be more than two parents, or a transgendered dad who is carrying the baby.

On intros, could ask “who is in this baby’s family?” Or “who will support you in birth and in the early weeks as a parent?” “Who is in your family? You and your child? You and a partner and child? Uncles and aunties?”

In class, refer to pregnant parent rather than “mom”, people in labor rather than “women in labor”, the uterus rather than “her uterus”, parents instead of “mothers.”

Don’t wait till you have someone in class who you know is transgender before you adapt your language. It’s hard to remember it in that one class! Consider just changing your language long-term for ALL classes to be as inclusive as possible so that it flows naturally when you do have that parent